Maryland Center of Excellence on Problem Gambling, University of Maryland Baltimore, MD, USA

Christopher Welsh

Maryland Center of Excellence on Problem Gambling, University of Maryland Baltimore, MD, USA

Seth Himelhoch

Department of Psychiatry, University of Kentucky, Lexington, KY, USA

Abstract

Problem gambling is highly prevalent and rarely treated among clients who attend methadone maintenance treatment programs (MMTPs). Compared with those of the general population, rates of gambling disorder have been found to be elevated among individuals receiving methadone maintenance treatment. Our study aims were to (a) develop a clearer understanding of the gambling experience of clients and counsellors at a methadone clinic and (b) gain insight into the current treatment options and obstacles to treatment in the clinic. Semi-structured interviews focusing on gambling issues were conducted with 8 clients and 8 counsellors at an MMTP located in an urban area. Participants were asked questions to gain an understanding about their perspectives on, treatment options for, and treatment barriers to problem gambling in the clinic. Data were coded by 4 investigators by using a constant comparison, open coding approach. The findings revealed important differences between clients and counsellors: Opinions differed on the definition of problem gambling, obstacles to treatment, and optimal treatment settings. Clients and counsellors also agreed on some elements, including the negative impact that problem gambling can have on recovery from substance use. This examination of responses of counsellors and client feedback provides a useful mechanism to better understand problem gambling in MMTPs. In addition, the findings have important clinical implications, including a need for more effective screening and treatment in MMTPs and to provide substance use counsellors with training related to problem gambling.

Introduction

Gambling disorder is highly prevalent and rarely treated among patients receiving methadone maintenance treatment, with rates of this disorder ranging from 7% to 52.7% among those in methadone maintenance treatment programs (MMTPs; Elman et al., 2016; Himelhoch et al., 2015; Leavens, Marotta, & Weinstock, 2014; Feigelman, Wallisch, & Lesieur, 1998; Spunt, Lesieur, Hunt, & Cahill 1995; Spunt, Lesieur, Liberty, & Hunt, 1996; Weinstock, Blanco, & Petry, 2006). For this study, the term gambling disorder is used to refer to those who meet four or more criteria from the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013) and the term problem gambling to refer to participants who do not meet the diagnostic threshold. Among MMTP patients, the combined prevalence rates of problem gambling and disordered gambling ranged from 17.7% to 30% (Elman et al., 2016; Himelhoch et al., 2015, 2016; Ledgerwood & Downey, 2002; Leavens et al., 2014; Spunt et al., 1996). In contrast, the rate of gambling disorder among the general population ranges from 0.4% to 4.2% (Lorains, Cowlishaw, & Thomas, 2011; Shaffer & Hall, 2001). Given that rates of gambling disorder are approximately 13-18 times higher among those receiving methadone maintenance treatment than among the general population, treatment for this disorder should be addressed in MMTPs.

Several studies have shown evidence that gambling disorder is associated with negative effects on patients’ engagement in substance use treatment (Leavens et al., 2014; Ledgerwood & Downey, 2002). Studies have also reported increased rates of drug use and illegal activities in clients under treatment for substance use disorder (SUD) who also meet the criteria for problem gambling. These findings present concerns that gambling may contribute to drug and criminal problems and impede recovery (Grant & Kim, 2001; Himelhoch et al., 2015, 2016; Langenbucher, Bavly, Labouvie, Sanjuan, & Martin, 2001; Spunt et al., 1996). Unlike other substance use treatment clinics, MMTPs follow a harm reduction approach. MMTP patients typically have poor general health; the goal of MMTPs is therefore to reduce the risks of drug use and improve the overall health quality of patients (Fillmore & Hohman, 2015; Puigdollers et al. 2004). Previous research has found that problem gambling among clients in methadone maintenance treatment is associated with significantly higher rates of treatment dropout and fewer total days spent in treatment (Ledgerwood & Downey, 2002; Himelhoch et al., 2016). Gambling treatment may be an important addition to MMTPs to complement other treatment strategies. With this addition to the treatment program, clients may be able to better engage in treatment and to stay in treatment longer than occurred previously, therefore continuing to lessen their risk.

Despite the negative effects that ongoing problem gambling appear to have on recovery, previous research showed a low percentage of treatment for gambling disorder during SUD treatment (14.3%; Leavens et al., 2014). Leavens and colleagues (2014) found that 26.5% of individuals reported that they needed to address gambling during their recovery and 30% had concerns that gambling could interfere with their future efforts to abstain from substances. These findings clearly indicate a need among SUD clients for treatment that focuses on problem gambling behaviours. Gambling treatment programs are scarce among the MMTP population; therefore, there is more to be learned about the effects of gambling interventions on substance abuse treatment. Petry, Rash, and Alessi (2016) reported that, in contrast to the results of previous studies, offering gambling intervention programs did not significantly affect SUD treatment outcomes. Given the limited research available about gambling interventions in substance use treatment clinics, it is unclear whether gambling interventions will have an impact on SUD treatment outcomes. However, considering the high rates of problem gambling among MMTP patients compared with those of the general population, treatment for problem gambling within MMTPs is still advantageous.

Unfortunately, despite some clients’ desire for treatment and the potential negative impacts of gambling on recovery, treatment for problem gambling for those who are in recovery is not readily available. Prior research examined the barriers to treatment among problem gamblers and found that one of the foremost barriers to initiating gambling treatment was treatment unavailability (Khayyat-Abuaita, Ostojic, Wiedmann, Arfken, Ledgerwood, 2015; Rockloff & Schofield, 2004). Even among problem gambling helpline callers who initiated treatment, treatment unavailability was reported to be the foremost barrier (17.7%; Khayyat-Abuaita et al., 2015). Several other studies have reported that individuals’ feelings of shame, embarrassment, or stigma were the most significant barriers to treatment (Gainsbury, Hing, & Suhonen, 2014; Rockloff & Schofield, 2004; Suurvali, Hodgins, Toneatto, & Cunningham, 2012). Additional barriers that have been reported are participants wanting to solve the problem on their own, difficulty admitting gambling was a problem, concerns about the cost of treatment, and concerns or uncertainties about the treatment itself (Gainsbury et al., 2014, Rockloff & Schofield, 2004; Suurvali et al., 2012). Participants did not report a lack of interest in treatment as a significant barrier in any of these studies.

A qualitative research method was used for the present study, as it allows researchers to gain a deeper and more nuanced understanding of gambling in the clinic. Previous studies have used qualitative methods to discuss perceptions of problem gambling among college students, homeless individuals, and clients in substance abuse treatment and have provided information on the development of treatment interventions for each of those populations (Guilcher et al., 2016; Holdsworth & Tiyce, 2013; Punzi, Tidefors, & Fahlke, 2016; Takushi et al., 2004). This approach allows researchers to gain invaluable information about the perceptions of gambling and gambling treatment and allows for the development of effective intervention approaches that can be used to improve treatment for problem gambling in methadone maintenance clinics. In the current investigation, we sought to do the following:

Develop a clearer understanding of the gambling experience of clients and counsellors at a methadone clinic.

Gain insight into the current treatment options and obstacles to treatment in the methadone clinic.

Method

Participants

Client recruitment

As we were specifically interested in including clients with an identified problem gambling disorder as assessed by a score of 4 or higher on the DSM-5 problem gambling questionnaire, participants were recruited from a previous study (5th ed.; APA, 2013; Himelhoch et al., 2016). Individuals were contacted for the present study if they had participated in the previous study, which examined the rates of gambling disorder in MMTPs, and provided written permission to be contacted for future studies. Participants attended an urban university-affiliated MMTP and were paid $30 for their participation. Interviews were conducted with eight clients, of whom 63% were female (n = 5) and 63% African American (n = 5). All participants met the DSM-5 criteria for gambling disorder in the previous study.

Counsellor recruitment

Counsellors at the same MMTP were approached during a staff meeting and informed about the study by research assistants. Counsellors were contacted for an interview if they expressed interest in participation and provided contact information during the meeting. They were paid $30 for their participation in the study. Interviews were conducted with eight counsellors, of whom 38% were female (n = 3) and 38% African American (n = 3).

Procedure and Materials

Semi-structured interviews

Semi-structured interviews were conducted by trained members of the research team. Participants provided informed consent prior to beginning the interviews. Client interviews took place at an off-site administrative building and counsellor interviews at the university-affiliated MMTP. Each interview lasted approximately 1 hr. All interviews were audio-taped and professionally transcribed verbatim with permission from client and counsellor participants. The present study was reviewed and approved by the institutional review board at the University of Maryland Baltimore.

In-depth interview guide

An in-depth interview guide was used that contained questions focused on clients’ and counsellors’ perspectives on problem gambling, opinions of screening for problem gambling behaviours in the MMTP, conversations (both clinical and informal) about gambling in the clinic, current treatment options available in the clinic, treatment approach suggestions for problem gambling behaviours, obstacles to treatment in the clinic, and problem gambling resources in Baltimore. In addition, clients were asked about types of gambling and their own personal gambling behaviours. The client interview guide is provided in Appendix A and the counsellor interview guide in Appendix B.

Qualitative Data Analysis

The research team used grounded theory for coding the data and identifying the emerging themes (Glaser & Strauss, 1967; Lapan, Quartaroli, & Riemer, 2012). Grounded theory strategies allowed researchers to use inductive processes to obtain data and develop theories on this underexplored topic (Byrne, 2001). Researchers used a constant comparison, opening coding approach. Four investigators took part in coding and analysing interview data; each interview was coded independently by two investigators. Investigators initially categorized data by interview questions, and then coded the data for each interview question. The coding process began with each researcher entering codes and corresponding supporting text in a database. Initially, each investigator had individual databases with codes and supporting text. Codes and emerging themes established by each investigator were discussed during coding meetings. If investigators agreed on codes, the code was finalized. If investigators found any discrepancies in codes, the discrepancies were discussed by all four investigators and codes were reconsidered. After open coding was finished, researchers constructed focused codes and created a finalized database of codes and supporting text. Researchers ended data collection when saturation was reached. This coding process allowed researchers to develop a grounded theory of the perceptions of problem gambling and barriers to problem gambling treatment in the clinic. Investigators met a final time to discuss the themes that had been created, reconcile any differences in codes of themes between investigators, and create a final list of emerging themes.

Results

In-depth interviews with clients and counsellors yielded six emerging themes. Counsellors and clients shared perspectives on three of these themes: gambling as a substitute for drug addiction, gambling as a trigger for relapse, and finances as a motivator for change. Interviews produced three additional emerging themes in which clients and counsellors expressed differing perspectives: definition of problem gambling, obstacles to treatment, and treatment setting.

Gambling as a Substitute for Drug Addiction

Clients and counsellors expressed agreement that gambling is often used as a substitute for drug use. Many counsellors stated that gambling is not a major focus at the clinic, but agreed that a gambling disorder could be detrimental to a client’s recovery from drug addiction. Counsellors mentioned that the thrill associated with gambling can be similar to the thrill clients achieved through drug use.

You’re anticipating the psychological and physical symptoms are almost identical in terms of this anxiety level, in terms of the hand sweating, the anticipation. You still go through the same array of symptoms as if you were going to buy drugs. (Counsellor 2)

The majority of clients agreed that gambling can be used as a substitute for drug use and acknowledged that problem gambling has many similarities to a drug addiction.

… you’re substituting it from one drug to really another. Not that it’s a drug, but it’s just as bad. You’re spending money on drugs, you’re spending money on gambling. (Client 3)

Table 1 shows the frequency count of the most common counsellor responses to the question, “Do you think that gambling can have an impact on your client’s recovery?”

Table 1 Counsellor Responses to “Do You Think That Gambling Can Have an Impact on Your Client’s Recovery?”

Table 2 shows the frequency count of the most common client responses to the question, “How do you think gambling could affect someone’s recovery from drugs/alcohol?”

Table 2 Client Responses to “How Do You Think Gambling Could Affect Someone’s Recovery From Drugs/Alcohol?”

Gambling as a Trigger for Relapse

As noted in Tables 1 and 2, counsellors and clients also reported that problem gambling behaviours not only mimic behaviours associated with drug addiction, but that problem gambling could also lead to a relapse to drug addiction. Counsellors specified that clients may be likely to use drugs both when they experience a sizable loss while gambling and when they experience a sizable win while gambling.

I think a lot of times, one of those things feeds off the other, because if they get the number, they’re going to buy an absurd amount of drugs. Vice versa. It has a crossover to it. (Counsellor 2)

Finances as a Motivator for Change

Clients and counsellors stated that financial struggles play a major role in clients’ recognition of problem gambling behaviours. Counsellors acknowledged that financial issues could be one of the clients’ only motivators for seeking change to their gambling behaviours (Table 3).

Table 3 Counsellor Responses to “What Do You Think Motivates Clients to Ask for Help With Problem Gambling?”

I think what would motivate them to ask for help is, as I said … if when bills came due they didn’t have the resources to pay them, especially when they’re well and not spending any more money on drugs. (Counsellor 4)

Clients agreed with counsellors and stated that they would only recognize that their gambling has become a problem when they can no longer pay their bills.

When I don’t pay my bills … My bills and puts me on the street, then yeah, that’s bad, or my lights get turned off … (Client 2)

Table 3 shows the most common counsellor responses to the question, “What do you think motivates clients to ask for help with problem gambling?” Six counsellors reported that money is a motivator for change. Four counsellors reported that monetary issues would trigger a client’s motivation for change. Two additional counsellors reported that a monetary incentive, such as a paid research study, would trigger change in clients.

In addition, several counsellors indicated that their conversations about gambling with clients revolve around financial planning (Table 4). Several counsellors mentioned that they use a money chart when discussing gambling with their clients in order to help them recognize that their gambling may be a problem.

Table 4 Counsellor Responses to “How Do You Talk to Your Clients About Gambling?”

People do the survey and they circle it, but not all of them are looking at the score sheet to see whether they made that level of problem or not … I’ve always gone over the money and … that seems to have a light bulb effect. (Counsellor 1)

Counsellors’ definitions of problem gambling differed greatly from clients’ definitions. The majority of counsellors stated that gambling becomes a problem when it has a major effect on an individual’s lifestyle and interferes with his or her ability to perform daily activities in a normal manner (Table 5).

Table 5 Counsellor Responses to “How Do You Define Problem Gambling?”

My definition of problem gambling is when it gets, it’s like an addiction, when it gets to the point where you’re not able to manage your day-to-day activities. Not so much debilitating as far as drug addiction, as far as you can’t get up in the morning, you’re always chasing, but as far as gambling, what I was explaining to my client is that you’re always trying to regain the loss. It’s the same. (Counsellor 8)

One counsellor defined it more specifically as a loss of control or a loss of focus on priorities.

I think every time I think of a problem, I think of loss of control. I think when it’s prevalent or there’s evidence of you losing control or not taking care of things that are a priority and you put things … like gambling or drugs or whatever the case may be in front of that, I think that identifies in some way loss of control which constitutes a problem. (Counsellor 6)

In contrast, when clients were asked to define problem gambling, all but one client defined problem gambling as overspending, or not being able to pay bills (Table 6). Several examples of client’s definitions of problem gambling are as follows:

Table 6 Client Responses to “What Does the Term Problem Gambling Mean to You?”

Problem gambling, it comes to a problem when it affects you paying your bills. You gamble on the odds. You can’t afford to do it but you do it anyway ... That’s when it becomes a problem. (Client 1)

Instead of getting my money order for my rent, first I go to the next window at the check cashing place where I get my money order and get scratch-offs and sit there and play them. (Client 2)

Problem gambling to me is when you had twenty thousand dollars and it be gone in a year. That’s a problem. (Client 6)

While counsellors acknowledge that a lack of money or overspending might be signs of a gambling addiction, it is not the only indicator of gambling addiction. Given that the overwhelming majority of clients defined problem gambling solely as overspending, clients seemed to be able to acknowledge gambling as an issue only if it was having an impact on their financial situation. Clients tended to not recognize gambling as a problem if it was not causing financial struggle.

If they’re spending all their money on gambling. If they’re constantly buying scratch offs or they’re constantly gambling on things like dog fights or anything really is a problem; but gambling is really bad for taking your money ... (Client 5)

Obstacles to Treatment: Issue Avoidance Versus Embarrassment

Counsellors stated various obstacles that interfere with clients seeking treatment for problem gambling, including lack of awareness, legality of gambling, lack of counsellor education, denial, and issue avoidance. Table 7 shows frequency counts of the most common counsellor responses to the question, “What are obstacles for clients receiving treatment for gambling?” Many counsellors thought that clients were unaware about the negative effects of problem gambling and suspected that to be the reason for clients not seeking treatment.

... A lot of us weren’t raised knowing how to save and what different savings accounts are, retirement funds, and all that. I think education about finances would probably help to raise a little bit more awareness about gambling. (Counsellor 1)

I’d just say a lack of insight, first of all. Like I said, a lot of people don’t identify it with a problem. (Counsellor 6)

One counsellor mentioned that their own education was also an obstacle to clients receiving help for their problem gambling. Counsellors are trained in substance use treatment and stated they did not have the resources or education to help clients with their problem gambling.

Maybe we need to have a counsellor here who is really versed on the questions that we can answer. I’ve been trained as a substance abuse therapist. As we go through this, I’m still learning where to refer, who to contact. Sometimes when patients come in and look for that instant gratification kind of thing, and if you don’t have it right there, they’re interest in it is deteriorating. (Counsellor 2)

Several counsellors stated that clients do not feel the need to address their gambling habits as an issue because they are able to function and pay their bills with their current gambling habits. Clients may not be seeking treatment because they do not want to address gambling as a problem and may be avoiding the issue.

Then some people say, “Oh, well, I pay all my bills first so I don’t have to worry about that.” (Counsellor 1)

A lot of people actually budget their income to ensure or accommodate that … A lot of them, it’s hard for them to really grasp it as a problem. (Counsellor 6)

It hasn’t really destroyed their life. They’re functional. (Counsellor 5)

Another counsellor reported that some clients were not only avoiding the issue of gambling, but were also denying it completely as a problem.

Oh, no, they’re not interested in any [resources] ... they denied it completely as a problem. (Counsellor 4)

In contrast, the majority of clients stated that guilt, shame, or embarrassment was the main obstacle keeping them from addressing their problem gambling habits (Table 8).

Table 8 Client Responses to “What Makes It Hard to Talk About Gambling?”

When you tell all the wrong things that you’ve done like, “Oh, I’ve took the rent money and my kids, or the light money,” you know? … Or “I took money that my kids didn’t get a pair of shoes …” To me that’s the hardest thing of just saying what you’ve done … the guilt. (Client 3)

For me, what makes it hard is when I talk about, I be embarrassed about when I start going downhill. Like, me having a problem and it got out of control, like I’d have messed up my rent money. Money that I was supposed to spend on my children—on my family. (Client 4)

Treatment Setting: Individual Therapy Versus Group Therapy

Another disconnect between counsellors and clients emerged when discussing treatment options for problem gambling. Table 9 shows the most common counsellor responses to “What are some treatments you think might be useful for methadone program clients with problem gambling behaviours?” Half of the counsellors stated that they believed that clients would prefer to discuss their gambling habits during a one-on-one session, whereas clients stated that they would prefer to talk about their gambling problems in a group setting. Counsellors also suggested psychoeducation, money management skills, and a modified screening measure as other potential treatment methods.

Table 9 Counsellor Responses to “What Are Some Treatments You Think Might Be Useful for Methadone Program Clients With Problem Gambling Behaviours?”

Counsellors shared a similar rationale for their belief that individual therapy would be a better setting to address gambling than a group setting. Given that finances are a personal topic, many counsellors thought that clients would not want to discuss their gambling habits in a group.

I usually do it in an individual setting because it’s personal when you start talking about finances with people. (Counsellor 8)

However, a majority of clients stated that they would like to attend a group or gambling-specific program for clients with gambling addiction. Clients also reported that it would be easier to talk about gambling if they had good rapport with their counsellor (Table 10).

Table 10 Client Responses to “What Would Make It Easiest to Talk About Gambling?”

It’s when I have other people sharing where they’ve been where I’m at and I see that “Wow, if they can do it, I know that I can do it.” So, it would help me to easy open up to admitting and to sharing that I really have a problem because I’m not by myself, I’m not the only one that went through this. (Client 4)

Overall Theme: Relatability

Throughout each interview, investigators noticed a common theme of relatability among clients. Clients indirectly mentioned numerous times throughout the course of the interviews that relatability is a crucial aspect to acknowledging and receiving treatment for problem gambling. The majority of clients stated that having counsellors who have gone through a similar experience was important to them in terms of talking about and treating their problem gambling.

It's a real big difference the counsellors that actually had an addiction problem and they on the other side now and they'd talking to us and letting us know that it's a way you can come out of that, then to someone who got the knowledge by book-wise and never even had a drug addiction or a gambling addiction. (Client 4)

What makes it hard to talk about gambling is the person don’t gamble. (Client 6)

One client in particular expressed strong feelings about the importance of having a counsellor with a history of addiction. This client stated that they could not relate to a counsellor who does not have a history of addiction and thinks that all counsellors at the substance use clinic should have a history of addiction in order to be able to effectively help clients.

The ones that come in there and work from the books, not from the streets, I can’t comprehend with. I can’t get with. I don’t get along with them because they think they know everything about me and they don’t know nothing even to begin with. I can’t ever explain. (Client 2)

Clients also discussed the importance of their relationship with their counsellor. Several clients stated that if they did not have a good relationship with their counsellor, they would be much less open to discussing gambling habits. In contrast, they stated that they would be willing to discuss those habits with counsellors they trust.

…You’ve got to find somebody that you can talk to and that’s the only way you’re going to fight it. (Client 8)

As demonstrated in this quote, clients felt that sharing experiences and personal stories would help them open up about their own gambling habits. Most clients expressed interest in having groups specifically for those with problem gambling.

Just go and talk about your addiction. Somebody might be saying the way you feel. They might be going through the same thing you’re going through. (Client 8)

A majority of clients were confident that they would attend a gambling group at the clinic if one were available. A few clients mentioned that the group would work like a networking system and that clients would encourage other clients to attend the group.

Here’s how it works. Say I’ve got a gambling problem, and you probably got a gambling problem, too. I’ll come to you and say, “The clinic got a good gambling group. You should go check it out.” You got to network. Even though he might think that he ain’t got no gambling problem, you can still get him to go with you. (Client 1)

In the present study, interview content revealed that counsellors believed that problem gambling is widespread among clients receiving treatment in the clinic, and counsellors acknowledged that problem gambling can be detrimental to a client’s recovery from SUDs. Surprisingly, clients also acknowledged the high prevalence of problem gambling behaviours in the clinic and recognized that problem gambling has similar symptoms to drug addiction and can lead to a relapse. These findings resonate with previous research that has found that gambling disorder is associated with negative effects on substance use treatment (Leavens et al., 2014; Ledgerwood & Downey, 2002). Although it is clear that both counsellors and clients are aware that gambling is a common problem at the clinic, the majority of counsellors did not report discussing or treating problem gambling behaviours. This finding is consistent with research suggesting low rates of gambling treatment in substance use treatment, despite a reported desire from participants for these services (Leavens et al., 2014). Given the high rates of problem gambling, it is imperative that treatment for problem gambling behaviours is offered in substance use clinics.

These interviews lend insight into the beliefs of counsellors and clients regarding their expectations and perspectives of gambling and gambling treatment in the clinic, shedding light on the differences between clients and counsellors. An examination of these inconsistencies will promote a better understanding of clients’ perceptions of problem gambling and may be able to help counsellors treat clients in a more effective manner.

The first difference was the stated cause of high rates of gambling in clients being treated in the clinic. Counsellors stated that clients’ lack of awareness and education about problem gambling caused them to be uninformed about the negative effects of gambling. Several counsellors implied that clients were becoming problem gamblers without recognizing that their habits may be unhealthy or addictive. However, in speaking with the clients, it was clear that the majority of them recognize that gambling is an addictive behaviour. Clients explicitly stated on several occasions that gambling is an addiction and can be used as a substitute for drug addiction. A previous study supports this finding and reported that 30% of participants were concerned that their gambling would have an impact on their recovery from substances (Leavens et al., 2014). Given that clients at the clinic are aware of the signs of addiction and relate gambling addiction to drug addiction, lack of awareness may not be the cause of the high rates of gambling.

Although lack of awareness may not be driving high gambling rates, client education could influence gambling rates. Research has found that gamblers often have irrational beliefs about gambling (Delfabbro, 2004). In the present study, a second inconsistency was discovered when the definition of problem gambling was discussed with clients and counsellors. Clients define problem gambling only in terms of financial struggle; the majority of clients stated that gambling becomes a problem when individuals are no longer able to pay their bills. Counsellors, on the other hand, define gambling in terms of lifestyle disruption. In their responses, counsellors implied that gambling is a problem when it has a major effect on an individual’s lifestyle and interferes with his or her ability to perform daily activities in a normal manner. Despite education on the odds of winning, many disordered gamblers continue to gamble and have strong beliefs that they will win. Disordered gamblers often win by persistence and frequent play, but allow those small wins to maintain their interest (Delfabbro, 2004). Persistent gambling is often not viewed as a problem to clients because they experience some success; however, this type of gambling can still become problematic. This discrepancy shows that clients focus on the more immediate problems of gambling and tend not to recognize other problems associated with their gambling behaviour. Clients may benefit from further education on the definition of problem gambling.

In addition to increased education, increased treatment options for problem gambling in the clinic may help address the issue. A third difference was revealed when discussing client and counsellor thoughts on the optimal treatment modality for problematic gambling. Counsellors believed that individual counselling sessions would be the best setting to discuss gambling behaviours and financial status because of the personal nature of the topic. Clients, however, stated they would prefer a group setting in which they could share stories and relate to others. The preference for a group setting rather than an individual setting was interesting considering that embarrassment was identified as a major obstacle to treatment. Although clients agree that they would not want to discuss their gambling or financial problems in public, they would be comfortable discussing them in a group if everyone in the group struggled with the same issues. Clients indicated a strong preference for personal stories, personal connections, and relatable counsellors. Clients also demonstrated a preference for counsellors who have histories of addiction. This finding demonstrates that clients are seeking empathy in their relationships with counsellors.

Empathy is defined in the therapeutic relationship as experiencing an accurate understanding of the client’s awareness of his or her own experience (Rogers, 1957). Empathy is a fundamental concept in the therapeutic relationship (Moyers & Miller, 2013; Norcross & Wampold, 2011) and many research studies have reported that empathy is associated with positive addiction treatment outcomes (Bein, Miller, & Tonigan, 1993; Fiorentine & Hillhouse, 1999; Meier, Barrowclough, & Donmall, 2005). The finding that clients of this MMTP request personal stories and counsellors with a history of addiction reveals that counsellors may not be demonstrating empathy towards their clients. This finding informs clinics that training in empathetic understanding is essential for counsellors to improve relationships with clients. Experiential learning techniques, such as improvisation, role play, and abstinence or behaviour change challenges, can be used to teach empathy to counsellors and students (Bayne & Jangha, 2016; Giordano, Stare, & Clarke, 2015; Warren, Hof, McGriff, & Morris, 2012; Yates, DeLeon, & Rapp, 2017).

The finding that clients prefer group treatment to individual treatment is also important when taking into consideration the cost-effectiveness of group treatment over individual treatment. Research has shown that group and individual therapy have similar outcomes, but that the group setting is a more cost-effective treatment format (Marques & Formigoni, 2001; Sobell, Sobell, & Agrawal, 2009). This suggests that a group specifically for those with problem gambling behaviours might be a cost-effective and efficient way to offer problem gambling treatment within the MMTP.

Clients and counsellors agreed that there are numerous barriers surrounding problem gambling treatment in the clinic. Each group, however, had distinct views on which of these obstacles was the main hindrance. Counsellors reported many obstacles to treatment, as discussed earlier, including lack of awareness, legality of gambling, lack of counsellor education, client denial, and issue avoidance. Many counsellors reported that they felt that issue avoidance was the main obstacle to treatment and that clients did not seek treatment because they were ignoring signs of problem gambling or in denial about having problem gambling behaviours. Clients, however, reported far fewer obstacles than counsellors did and stated that their main obstacle to treatment was guilt, shame, and embarrassment. This suggests that lack of awareness, denial, and issue avoidance may not be the client’s main obstacles for seeking treatment for gambling addiction; instead, embarrassment may be a leading obstacle. This finding reinforces previous research that psychological barriers such as pride, shame, and stigma are the leading barriers to treatment (Pulford et al., 2009; Suurvali, Cordingley, Hodgins, & Cunningham, 2009; Suurvali et al., 2012). Minimization or issue avoidance were also reported as major obstacles to treatment in previous studies. Lack of awareness or knowledge and logical issues were mentioned to a lesser degree (Pulford et al., 2009; Suurvali, Cordingley, Hodgins, & Cunningham, 2009). A change in protocol for discussing problem gambling behaviours in the clinic may be necessary to better address this issue.

Current clinic protocol includes a brief screening for problem gambling during intake, but does not outline any follow-up procedures for discussing the results of the problem gambling screen. A majority of counsellors reported that they discuss gambling habits after intake only if their clients bring them up. There were a variety of reasons for this, including (a) that the counsellors thought drug addiction took priority over gambling, (b) that the counsellors were unaware of the client’s score on the gambling questionnaire completed during intake, and (c) that the clients denied having a gambling problem. These responses suggest that it may be beneficial for clinics to develop a protocol for discussing gambling habits with clients who were identified as problem gamblers during intake.

Along with client education, several counsellors suggested that counsellor education could be an obstacle to treatment. Several participants mentioned casual and social discussions of gambling with their counsellors, for example, talking about the games or numbers they intended to play. One participant accused the counsellor of having a gambling addiction. This is consistent with research showing that substance abuse counsellors struggle with problem gambling at much higher rates than the general population does (Knopt, 2005; Weinstock, Armentano, & Petry, 2006). MMTP counsellors are trained to address SUDs; therefore, many stated that they do not feel they have the knowledge to treat problem gambling. Several counsellors stated that they would be interested in receiving more education on gambling. Others suggested that hiring a counsellor specifically for problem gambling at the clinic might be a more effective way to address the issue. If education on problem gambling were increased among the counsellors, more MMTP clients might be able to receive education and services. Further investigation should focus on the most effective ways to train traditional addiction counsellors to ensure they are prepared to discuss problem gambling with clients.

Limitations

Although we achieved our research aims in this study, several limitations should be noted. First, because of the exploratory and qualitative nature of this study, the sample size was small. This was also a convenience sample and may not be generalizable to other urban substance use treatment clinics. Future research should conduct a multi-site study to explore a larger and more diverse sample. This is one of the first qualitative investigations to explore the perceptions of problem gambling in a substance use treatment setting and provides a promising starting point for further investigation.

Conclusion

Although increased prevalence of problematic gambling in MMTPs has been reported for well over a decade, there continues to be a lack of screening and treatment services provided in these clinics. In our study, both clients and counsellors recognized the high prevalence of problem gambling among clients treated in the clinic, but also acknowledged that efforts are not being made to address the issue. We identified that clients are aware of the financial consequences of their gambling habits, but established that further education needs to be provided about the effects of gambling on recovery from drugs. Clients demonstrated a strong preference for treatment options that did not make them feel singled out; they preferred group over individual therapy, requested personal stories in the literature about problem gambling, and heavily preferred counsellors with a history of addiction. This highlights the need to make clients feel comfortable and understood when they are receiving treatment. Counsellors demonstrated a need for further training about techniques for treating problem gambling and appeared to be open to receiving education. Finally, standardization of clinic procedures for addressing problematic gambling might help clinicians to more effectively recognize and treat problem gamblers. The hope is that the results of these qualitative interviews may help programs address some of the barriers that appear to continue to hamper efforts to provide services that address problematic gambling in MMTPs. A combination of both counsellor and client education and clinic policy change may help launch more treatment of problem gambling in substance use treatment settings.